1. Waiver Renewal and Transition Year Updates May 4, 2016 Amanda Broden, HHSC, 1115 Transformation Waiver

2. Goals of 1115 Transformation Waiver Expand Medicaid managed care statewide Develop and maintain a coordinated care delivery system Improve health outcomes while containing costs Protect and leverage federal match dollars to improve the healthcare infrastructure Transition to quality-based payment systems across managed care and hospitals 2

3. Extension Request for the Pools The extension request on the funding pools: DSRIP pool equal to demonstration year (DY) 5 funding level for DSRIP ($3.1 billion annually) Uncompensated Care (UC) pool equal to the unmet need in Texas, adjusted to remain within budget neutrality each year (ranging from $5.8 billion - $7.4 billion per DY) The Centers for Medicare and Medicaid Services (CMS) required that Texas submit a report prior to waiver extension related to how the two pools in the waiver interact with the Medicaid shortfall and what uncompensated care would be if Texas opted to expand Medicaid. 3

4. Extension Request for the Pools (cont.) HHSC recently submitted a request to CMS for an initial 15-month extension at level funding from demonstration year (DY) 5 of the waiver during which negotiations will continue on a longer-term agreement. 4

5. Texas DSRIP Extension Principles Further incentivize transformation and strengthen healthcare systems across the state by building on the Regional Healthcare Partnership (RHP) structure. Maintain program flexibility to reflect the diversity of Texas’ 254 counties, 20 RHPs, and almost 300 DSRIP providers. Further integrate with Texas Medicaid managed care quality strategy and value based payment efforts. Streamline to lesson administrative burden on providers while focusing on collecting the most important information. Improve project-level evaluation to identify the best practices to be sustained and replicated. Continue to support the healthcare safety net for Medicaid and low income uninsured Texans. 5

6. Evolving Federal Perspective Based on Recent Waivers Recent DSRIP programs are more standardized, increasing accountability by incorporating more outcomes-based payments, and operating through community partnerships. ( Source: NASHP report for MACPAC, March 2015 ) CMS has communicated two directions for future DSRIP (for all states): Sustainability - DSRIP should not be considered an ongoing funding source Implementation of Alternative Payment Methodologies (APM), similar to value-based purchasing 6

7. DSRIP Protocols Texas indicated to CMS in the extension request that we plan to propose ways to strengthen the DSRIP program in the extension period. DSRIP requirements in the extension period will be defined in the revised DSRIP protocols - the Program Funding and Mechanics Protocol (PFM) and the RHP Planning Protocol (DSRIP menu). HHSC will continue to consider stakeholder feedback as we work to finalize the protocols for submission to CMS. 7

8. DSRIP Planning and Negotiations with CMS HHSC plans to: Submit to CMS the proposed protocol language for the Transition Year (DY6) in Spring 2016; Post for stakeholder feedback the proposed protocol language relating to replacement and continuing projects for DY 7-10, as well as funds not dedicated to projects, in late 2016/ early 2017. HHSC will submit high-level proposals to CMS for consideration on an ongoing basis. Based on CMS feedback about the feasibility of various elements, HHSC then will work with stakeholders to develop detailed requirements. 8

9. DSRIP Protocols Initial proposals planned: Transition year (DY 6 - 10/1/2016 – 9/30/2017) Includes parameters for combining projects Laying the groundwork for performance bonus pools Setting a minimum annual valuation amount per provider Revised protocols for extension/renewal (beginning 10/1/2017) Continuing and replacement projects Regional performance bonus pools 9

10. Transition Year (DY 6) HHSC has proposed to CMS that current projects that are eligible to continue or will be replaced be eligible to continue for a transition period of one year (DY 6), including 2.4, 2.5, 2.8 and 1.10 projects. A high level Transition Plan was submitted to CMS in November 2015 10

11. Transition Year (DY 6) HHSC posted a proposed Transition Year (DY6) Program Funding and Mechanics (PFM) Protocol on the waiver website with a survey for stakeholder feedback. HHSC is reviewing stakeholder feedback and revising the proposed protocol language as appropriate to incorporate/address feedback. HHSC plans to submit the revised protocol language to CMS in Spring 2016. In summer 2016, providers submit confirmation of whether they plan to 1) discontinue their project, or 2) continue/replace their project. 11

12. Transition Year (DY 6) (cont.) Each Cat. 1-2 project must have the following four milestones in DY6, each valued at 25% of the project’s DY6 valuation: – Total QPI – MLIU QPI – Core Component Reporting Same as current “Project Summary” tab in DSRIP Online Reporting System: “Project Overview: Accomplishments,” “Project Overview: Challenges,” etc., with an additional question relating to the provider’s participation in learning collaboratives. – Sustainability Planning 12

13. Transition Year (DY 6) (cont.) Cat. 1-2 Sustainability Planning – HHSC will develop a template for reporting. – Providers will be required to submit qualitative descriptions of sustainability planning efforts. – Planning efforts could include: Integration with managed care Health Information Exchange (HIE) Other community partnerships 13

14. Transition Year (DY 6) (cont.) Cat. 1-2 Sustainability Planning – HHSC and Anchors will help facilitate discussion through statewide and regional learning collaboratives. – Strategies will differ based on provider, project type, and target population. – Possible tool to help providers with planning: Center for Public Health Systems Science, George Warren Brown School of Social Work, Washington University in St. Louis: https://sustaintool.org/https://sustaintool.org/ Includes 40 questions across 8 domains. Domains include environmental support; funding stability; partnerships; organizational capacity; program evaluation; program adaptation; communications; and strategic planning. Responses identify sustainability strengths and challenges, which can then guide sustainability action planning. 14

15. Transition Year (DY 6) (cont.) Category 3: Current Proposal for Transition Year – For each Cat. 1-2 project, the respective Cat. 3 outcome values for DY5 are summed; then, for DY6: 50% of Cat. 3 valuation is pay-for-reporting (P4R) for continuing to report the Cat. 3 outcomes reported in DY5, including population focused priority measures 50% of Cat. 3 valuation is P4R for completing and submitting a Cat. 1-2 project-level evaluation in DY6. – Performing providers may carry forward Cat. 3 milestones from DY6 to DY7. 15

16. Transition Year (DY 6) (cont.) Category 3: Alternate Proposal for Transition Year – CMS has noted that under the current proposal, there is not a pay-for-performance (P4P) component in DY6. – If CMS requests a P4P component in DY6, HHSC may propose to continue current Cat. 3 P4P outcomes as P4P in DY6. 16

17. Transition Year (DY 6) (cont.) Category 4: Performance Bonus Pool (PBP) 5-10% of DY6 valuation per provider is set aside for the Performance Bonus Pool (PBP) to reward high performing regions and pay providers based on regional agreement on, and selection of, performance measures. HHSC will establish the PBP measures that will be required for all regions, and will develop a list of additional potential PBP measures that a region can select based on the key community needs and DSRIP areas of focus in that region. – A draft list of regional PBP measures under consideration, including the measures in the ICHP statewide analysis plan, has been posted on the HHSC website with instructions for providing feedback. 17

18. Transition Year (DY 6) (cont.) Category 4: Performance Bonus Pool (PBP) HHSC will use state-generated data instead of provider-generated data for the PBP measures. HHSC will need to ensure that there is no duplication of federal funds (e.g., if PPEs are used for the PBP). HHSC seeks stakeholder input on potential Medicaid measures and all- payer measures to help reflect the improvements in healthcare delivery in Texas during the waiver period. 18

19. Revised Protocols for DY 7 Forward The information on the remaining slides is proposed to be effective beginning 10/1/2017 (for DY 7 through DY 10, or for the extension period approved by CMS). 19

20. Continuing Category 1 & 2 Projects All projects from areas included on the 3-year menu are eligible to continue unless otherwise notified by HHSC in January 2016. There are many promising projects that need more time to demonstrate outcomes and evaluate best practices. Some projects may be required to take a next step and HHSC may propose further standardization of continuing projects (including related to QPI and project intensity). There will be fewer, more standardized milestones/ metrics to report for achievement. 20

21. Replacement Projects Replacement projects may be submitted in the following circumstances, contingent on CMS approval: Four-year projects from 2.4, 2.5, 2.8, and 1.10 project areas (except 1.10 for learning collaborative purposes, which may continue) Providers of projects withdrawn after June 30, 2014 (so associated funds are not currently allocated to active projects) Projects identified from high risk list based on HHSC review Providers may also elect to discontinue a current project(s) and propose a replacement May be proposed up to the same valuation as original project, not to exceed $5 million per demonstration year 21

22. Replacement Projects (cont.) HHSC reviewed the projects that were identified as potentially not being eligible to continue (or may require changes to the project scope, milestones/metrics, and/or valuation). HHSC notified these projects of the results of the project review in January 2016 to give providers time to plan for replacement projects if needed. These providers may propose replacement projects selected from the extension menu, contingent on approval from CMS. Replacement projects would be submitted to HHSC during DY 6 at a date TBD (such as a target date of January 1, 2017) upon CMS approval of the revised RHP Planning Protocol. 22

23. Replacement Projects (cont.) Providers will have to decide by Summer 2016 whether to 1) discontinue their project, or 2) continue/replace their project. If they decide in Summer 2016 to continue/replace, they will have until March 2017 (immediately prior to April DY6 reporting) to change their mind without financial penalty. HHSC may consider a withdrawal window in DY7 or DY8 without recoupment of DY6-7 payments, subject to CMS approval. Timeline for development of DY7-10 protocols: Late 2016 / Early 2017: Protocol information on replacement and continuing projects for DY7-10, as well as funds not dedicated to projects. 23

24. Extension Menu Replacement projects must use options outlined in the extension menu. The Category 1 & 2 draft extension menu is designed to build on the lessons learned from DSRIP in the initial 5-year waiver. The extension menu is a streamlined version of the current RHP Planning Protocol - combined similar project options and removed selected project options to keep the most transformative options on the menu. Opportunities to “hit the ground running” through replication of strong, existing projects with limited or no planning period. Project options not included on the extension menu often may be a component of a project in the extension. Some project areas and options were consolidated to avoid duplication of options across project areas. Best practice options for some project areas were added to the draft extension menu. 24

25. Extension Menu (cont.) Information from Transformation Impact Summaries and input from Clinical Champions was considered during the development of the draft extension menu. Replacement projects and metrics will be more standardized than the current DSRIP menu. HHSC plans to develop templates for submission of replacement projects, including core components. Project options included in the draft extension menu are shown in the Summary of the Transformational Extension Protocol (posted on the HHSC waiver renewal webpage). Stakeholders may provide feedback on the proposed extension menu via the online survey posted on the waiver website. 25

26. Items in Development Ongoing communications process for stakeholder feedback Timelines Extension menu – stakeholder feedback continues to be incorporated Replacement project requirements QPI requirements for DY 7 forward Additional Category 1 or 2 standardized metrics Potential changes to Category 3 measures Regional performance bonus pool measures and funding Further uses for funds not allocated to active projects 26

27. Waiver Communications Find updated materials and outreach details: http://www.hhsc.state.tx.us/1115-waiver.shtml Submit questions to: TXHealthcareTransformation@hhsc.state.tx.us 27